Child and Adolescent Psycho-pharmacology Update
Stay current with the most successful approaches to treating common
childhood disorders. This newsletter covers the latest research findings, off-label
prescribing practices, case reports, adverse events, and more to keep
you informed.
Read More

A bill that would classify homelessness as a health problem and require insurers to provide coverage for the treatment of homelessness is currently under consideration in the Hawaii state legislature. The sponsor of the legislation wants to cure homelessness with housing by redirecting some of the state’s $2 billion annual Medicaid budget to pay for it.

A bill that would classify homelessness as a health problem and require insurers to provide coverage for the treatment of homelessness is currently under consideration in the Hawaii state legislature. The sponsor of the legislation wants to cure homelessness with housing by redirecting some of the state’s $2 billion annual Medicaid budget to pay for it.

According to news reports, Hawaii had the highest rate of homelessness of all U.S. states in 2015, with 53 homeless people for every 10,000 residents, according to the National Alliance to End Homelessness.

The Hawaii legislation, SB 2, specifies that “each individual or group accident and health or sickness insurance policy issued or renewed in this state after Jan. 1, 2018, shall provide to the policyholder coverage for the treatment of homelessness.”

The bill may be the first of its type introduced nationally. “I’ve not heard of any legislature of this kind,” Senator Josh Green, M.D., sponsor of the bill, told MHW. People are often struggling with a mental illness or drug addiction or regular health challenge because they’re homeless, said Green. “Sometimes homelessness accompanies these issues and sometimes it’s made worse by it,” said Green, an emergency room doctor. “I’ve been able to take care of a lot of people that are homeless.”

Cost projections

People who are homeless in Hawaii tend to need very high-end care, Green said. They go to the emergency room, where they utilize anywhere from $75,000 to $150,000 of health care services, Green noted. “They can’t make good decisions for themselves to get basic care,” said Green. “Sometimes they have no identification and no way to get to the clinic.” Many go to The Queen’s Medical Center, considered the best in Hawaii, he said. It has no clinic, said Green, but it offers full acute care.

Green added, “Over a billion dollars of Medicaid dollars get spent delivering important care.” Homeless patients may need to see a psychologist and receive basic medication, and they need a roof over their heads, he said. “My reason for using taxpayer dollars is that they are already contributing to Medicaid; why not use it better [toward helping the homeless]?” he said.

Medicaid funding could be put toward a better use of resources and pay for care coordination, said Green. “As a legislator, I operate under the assumption [that it’s going to be] an uphill battle finding new funding from colleagues,” he said.

The state had a $2 billion Medicaid budget, Green said. “We should spend 20 percent of it on housing,” he said. Green pointed to a recent state survey that found that health care costs for chronically homeless people dropped 43 percent when they had decent housing.

About $3 trillion a year is spent on health care globally, he said. About 8,000 to 12,000 people are homeless in Hawaii; 1,300 are chronically homeless, Green added. “If we focus on the 1,300 that are chronically homeless, we could save $100 million,” he noted. “We could invest $400 million and see $500 million in return. This could be a game changer.”

A person who is chronically homeless may become a victim of violence or a sexual assault or end up in prison for 75 thousand a year, said Green. “These are all the reasons I developed this concept. It will take some time for people to understand,” he said.

Sheltering the chronic homeless

“We’re expecting the Trump administration to move Medicaid to a block grant,” said Green. “It’s Republican ideology to use the argument to say it’s the state’s right. If they say that, and we go toward a block grant, I think it’s a bad idea,” he said. “I’m encouraging our state to shelter the chronically homeless and invest in better programs.”

Hawaii expanded its Medicaid program three years ago, prompting an increase from 285,000 people to 362,000, Green noted.

Green said he will work closely with his colleagues on this bill. The first public hearing was held last week. Another hearing with amendments is scheduled for Feb. 6. “I’ll impress upon them the need for new solutions,” he said. “We’re looking at helping people in a desperate state. It’s the most novel [approach] we’ve got.” Green admits the legislation could take a few years to pass.

The director of the National Coalition for the Homeless says the housing market is extremely unaffordable across the country. “We’ve been saying for a very long time that housing itself is a [public] health problem,” said Megan Hustings. “We have not heard of a similar bill.”

Hustings added, “We really can’t afford to get rid of the ACA [Affordable Care Act],” she said, particularly for people who are living on the street. “Medicaid is extremely helpful in providing wraparound services that could keep someone in housing.”

She added, “Oftentimes mental illness appears after someone becomes homeless, after they lose their home and are experiencing the trauma of homelessness. Some think it’s the reverse; that’s a commonly held stereotype.”

Federal challenges

The executive director of the Technical Assistance Collaborative, a national organization that provides technical expertise to organizations and policymakers in the areas of mental health, substance abuse, human resources and affordable housing, said that Medicaid is statutorily prohibited from paying for room and board. “Even if classified as a medical condition, federal statute prohibits the use of Medicaid funds for housing,” Kevin Martone told MHW.

Martone noted that a couple of states (New York and Illinois) tried to get permission from the Centers for Medicare & Medicaid Services to pay for housing but were denied. “As a result, they are using state savings to pay for housing,” he said.

“Housing is a social determinant of health,” added Martone. “But, by suggesting Medicaid pay for housing, we are sending a message to our policymakers that we don’t need new resources at HUD [U.S. Department of Housing and Urban Development] dedicated to housing assistance.”

Martone pointed to the ongoing “attack” at the federal level and the federal government’s attempt to significantly reduce spending. Many could lose coverage under the ACA, he said. “There are waiting lists in states for services, and we have workforce shortages due to low reimbursement rates,” Martone said. “Medicaid savings should support services first.”

“The homelessness and disability community are desperate for housing solutions because federal and state government have not sufficiently addressed the affordable housing crisis,” said Martone.

Martone added, “Congress made significant progress in the past few years eliminating veterans’ homelessness because they paid attention to it and allocated resources. The homeless, health care and disability communities need to partner with the affordable housing [community] to urge policymakers to prioritize affordable housing resources as they did for veterans.”

Observing that mental health is one of the biggest public health issues currently facing their communities, Minnesota hospital and health system officials have embarked on a campaign to engage the public in a statewide conversation about mental health and work with community partners to spread the message.

Observing that mental health is one of the biggest public health issues currently facing their communities, Minnesota hospital and health system officials have embarked on a campaign to engage the public in a statewide conversation about mental health and work with community partners to spread the message.

The Minnesota Hospital Association on March 31 launched its “Strengthening Healthy Communities” campaign using the hashtag #HealthyMinds. The campaign aims to feature stories about the impact of mental health issues from the perspective of the patient, families, law enforcement, schools, health care providers and other community members, officials announced in a press release.

“With this public initiative we intend to turn up the volume on the needs and create additional focus on the biggest health issue facing our state,” Wendy Burt, spokesperson for the Minnesota Hospital Association, told MHW. “We’ve been hearing from our hospitals’ 140 members throughout metropolitan and rural areas who feel the state cannot meet the demand for mental health services.”

Burt added, “We conducted a poll in late October that found that 85 percent of respondents say mental health is a serious problem in the community. That’s a big number.” One in four respondents said they knew someone who missed work due to depression or anxiety, she added. “It’s touching virtually everyone in the state,” said Burt.

The initiative will help to increase public education about mental health and reduce stigma, noted Burt. Currently, the National Alliance on Mental Illness (NAMI), one of the hospital system’s community partners, is pushing forward its #makeitokay campaign, a public service announcement to also reduce mental health stigma.

The NAMI campaign and the Minnesota Hospital Association’s health partner are making much headway in getting people comfortable in talking about mental health, Burt said.

Multiyear effort

The multiyear effort is grounded in five core principles that hospital and health system officials said are essential in reforming the complex mental health system in Minnesota:

Share experiences — Building greater awareness of mental health challenges and improving care starts with community members sharing their experiences and learnings.

Engage early and often — Treat mental health by recognizing conditions early and ensuring Minnesotans have access to appropriate levels of care.

Foster stronger community partnerships — A communitywide approach is required to develop safe, effective and culturally competent solutions to identify and treat mental health conditions among all Minnesotans regardless of geography, income, ethnicity, gender or age.

Use good data to make informed decisions — Consistent reliable data will inform well-founded solutions to mental health.

Expand education, innovation and technology — Minnesota can identify and treat mental health conditions by using the latest technology and innovations, and ensuring communities have access to qualified, trained mental health specialists.

“We also are working with groups that represent community-based clinics,” Burt said. “There are a lot of local efforts going on.”

One such effort is a partnership between Park Nicollet Methodist Hospital and St. Louis Park Middle School called NOW (No Obstacles to Well-being) to provide telemental health services to the students via videoconferencing. In a Facebook video, officials have noted only one child psychologist in the state per 17,000 students. “We will be running Facebook posts and Facebook ads as well to turn up the volume on this issue,” said Burt.

A priority issue

The hospital has identified mental health as a priority moving forward, said Shannah Mulvihill, executive director of Mental Health Minnesota. “They’re acknowledging that mental health plays a key role in our community,” Mulvihill told MHW. “We will likely jump in playing a role at some point, helping share stories about what experiences [consumers] are having and how to improve the system to serve them better.”

The state is making other efforts to improve its mental health system, said Mulvihill. Minnesota is one of the 24 states selected to participate in the first round of federal demonstration programs to help states establish certified community behavioral health clinics. The U.S. Department of Health and Human Services awarded Minnesota $982,373 in planning grants to support the state’s efforts to improve the behavioral health of their consumers by providing community-based mental health and substance use disorder treatment.

“Our state legislature is putting the pieces in place to move that forward,” Mulvihill said of the bills (Senate File 2549, House File 2609). “The legislation will help us do what we need to do and make us competitive," she said. “The care will be a very integrated model of care. Clients will be addressing more of the whole person. Support will include housing and physical health care. You can’t isolate one condition." Meanwhile, this fall, eight states will be selected to participate in the two-year pilot program, Mulvihill noted.

A new rule by the Maine Department of Health and Human Services to address service eligibility for adults and children with mental illness who receive Medicaid along with a review of provider rate adjustments has sounded the alarm for the entire mental health community who fear business closures and subsequent loss of services.

A new rule by the Maine Department of Health and Human Services (DHHS) to address service eligibility for adults and children with mental illness who receive Medicaid along with a review of provider rate adjustments has sounded the alarm for the entire mental health community who fear business closures and subsequent loss of services.

Hundreds of Maine consumers turned out March 25 during a public hearing to oppose Gov. Paul LePage’s administration’s eligibility changes to Section 17 of the MaineCare rules. The plan limits automatic eligibility to Mainers with schizophrenia or schizoaffective disorder, potentially leaving behind Mainers with post-traumatic stress disorder, major anxiety disorder and other diagnoses, according to a press release from Rep. Drew Gattine’s (D-Westbrook) office.

Maine lawmakers on April 6 voted to keep services in place to help Maine consumers with mental illness stay in their homes and avoid costly hospitalization and residential services. The committee’s bill provides at least a 120-day transition period for each individual affected by the DHHS’s plan, and if alternative services are not available, a 90-day extension through June 30, 2017.

The new rule regarding Section 17 took effect April 8. Meanwhile, the legislative proposal will need to be presented before the full legislature.

David Sorensen, an aide in Gov. LePage’s office, in a March 31 editorial to The Portland Press Herald, wrote that of the 17,000 people currently served by Section 17, the department estimates that about 8,000 have these less-severe diagnoses. Meanwhile, there are 350 people on waitlists for these services, many of them requiring the higher level of care that Section 17 was originally intended to provide, Sorensen wrote.

Provider rate adjustments

Proposed provider rate adjustments have also raised concern in the provider community. Samantha Edwards, DHHS spokesperson, said there are no “proposed cuts” but rather draft rate models prepared by Arizona-based Burns & Associates and the DHHS for provider review and comment, she said.

The rates are for services provided under various sections, including Section 17, of the MaineCare policy. “Before proposing new final rates, the department will review provider comments and respond to each in writing — either agreeing and adjusting rate models accordingly or disagreeing and explaining why — as has been the practice for each of the prior four rate studies that the department has conducted with Burns & Associates,” she noted.

Edwards added that the DHHS is committed to ensuring that MaineCare rates adequately support delivery of services authorized under the program. As noted earlier, the current rate study is the fifth the department has conducted over the past two years with Burns & Associates. We have found their work to be exceptional, and the rate studies they have produced have been well-received.

The DHHS is at the midpoint of the rate review process, and the department extended the comment period to May 16, giving providers and stakeholders two months to provide feedback on the draft models, Edwards said.

Once the comment period closes, the DHHS and Burns & Associates will review each submission and respond in writing, either accepting the comment and incorporating its recommended changes into the rate model(s) or explaining their disagreement with the comment, said Edwards. “Herein, our goals are transparency in our reasoning, granularity in our analysis and thorough engagement with providers and stakeholders,” she said.

Legislative action

As the DHHS prepares to move consumers from one Medicaid program to another, the legislative proposal is expected to move to the full legislature, said Rep. Gattine, co-chair of the legislature’s Health and Human Services Committee. “We’re telling the department to provide for a longer transition period,” Gattine told MHW.

“There are concerns that people aren’t ready to make the transition because behavioral health homes are a relatively new service in the state,” he said. There are capacity issues in geographic parts of the state, Gattine noted.

The department’s plans regarding provider reimbursement rates are technically a separate issue but are very much related, noted Gattine. The provider rate proposal reduction would range anywhere from about 25 to 50 percent, he said.

“Providers are telling us that if the department moves forward there would be thousands of adults and children [without services],” he said. The problem is the department proposed a rate cut last year during its budget session, which was rejected by legislators, he said.

The DHHS had until January of this year to release another proposal regarding the provider reimbursement rates; however, they never did, he said. It wasn’t until March when they presented the rate proposal, he said. “Providers will be in a very compromised position with the rate cuts,” said Gattine. At MHW press time, a meeting had been scheduled to address the proposed rate adjustments.

Gattine said he is hoping the department will delay its proposal until the legislative session resumes January 2017. The current session is expected to end April 20, he said. “We’re now at the end of the session and the department is proposing these cuts,” Gattine said. “We’re not in a budget crisis. We’re not trying to fill a budget hole.”

Gattine added, “This is a very hot topic and a topic of great concern to the people.” For the past 30 years, Maine has been pretty much operating under a consent decree, he said. The consent decree plays a huge factor in how mental health services can be provided in the state, he said.

“The consent decree has a lot of bearing on how services can be developed for people in the community,” he said. “It’s been a real struggle for us to create a quality mental health system. We can’t afford to take a step backward. We’re looking very hard at building a mental health system we can be proud of.”

Advocacy, peer concerns

Aashley Malsbury, policy associate at the National Alliance on Mental Illness Maine, said the DHHS’s proposal would have a devastating impact, not just on consumers receiving MaineCare, but on the state’s entire mental health system as well. “Providers can’t keep their doors open with the suggested proposal,” she told MHW.

The proposed rule would impact about 8,000 consumers with mental health needs who aren’t currently receiving services under MaineCare, said Malsbury. New eligibility criteria would apply to individuals diagnosed with bipolar disorder or schizophrenia, and who might be at risk of homelessness, criminal justice involvement or hospitalization, she said.

NAMI Maine submitted written testimony highlighting their concerns and its impact on peers utilizing services, and the unnecessary anxiety caused by the notices consumers received, she said. The notices about the changes to Section 17 were sent to consumers before being sent to providers, Malsbury said. NAMI Maine raised concerns because the service eligibility under the new rule should be more specific to the need for that type of service, rather than the diagnosis, she said.

Under the rule, a person with schizophrenia would receive case management services. One-third of people diagnosed with schizophrenia would experience only one episode of psychosis in their lifetime, she said. They would automatically be eligible to receive those services. It would not be based on need, Malsbury said.

According to the Burns & Associates rate study, the reimbursement rate cut for providers of adult case management services would be reduced by 28.7 percent. The rate for a physician or nurse practitioner for medical management services would be reduced by 47.8 percent, she said. “The proposed rate cuts would have a devastating impact on the mental health system as a whole — not just on those receiving services through MaineCare. Providers can’t keep their doors open with the suggested proposal,” she said.

Although pleased with the momentary reprieve from lawmakers courtesy of legislation to extend the transition to services, peers are concerned that the department’s proposal could mean potentially closing four of the state’s 12 recovery centers, said Marge Grant, coordinator of Friends Together Peer Support and Recovery Center in Livermore Falls.

“We could lose our contract,” Grant told MHW. “They want to close four of the 12 recovery centers in the state of Maine,” said Grant. The recovery center receives the bulk of its funding from the DHHS, she added.

The center, in operation for 20 years, provides social, leisure, educational and recreational services to promote recovery among its members, along with nutritional and wellness support, Grant said.

Representatives from the Maine Association of Peer Support and Recovery Center participated in the state hearing on March 25 to air their concerns, she noted.

The legislative proposal introduced April 6 is a step in the right direction, said Grant. “Unfortunately, it’s not going to happen overnight,” she said. “We’re now waiting to see [what more] the legislature is doing going forward. We’re trying to get this all figured out.”

Bottom Line…

The DHHS plan that includes provider rate adjustments is still being addressed by lawmakers.

The debate over the name of the 51FIFTY energy drink and whether it’s offensive to people with mental health issues has taken an unusual twist, The Fresno Bee reported April 5. The Livingston, California–based energy drink landed in the spotlight two weeks ago when Save Mart said it was pulling the drink from its shelves in response to pressure from mental health advocates, several of them from Fresno. The advocates said the drink’s name and the “Live The Madness” slogan printed on the can contribute to the stigma faced by people dealing with mental illness. Police and first responders use the term “5150” in situations when a person “as a result of a mental health disorder is a danger to others, or to himself or herself, or gravely disabled.” Carlos Vieira, 51FIFTY CEO, refuses to change the name. According to the drink’s website, the name represents “a person who never quits, meets all challenges head on, doesn’t feel fear, pushes the limit and is crazy enough to chase his or her dream.”

Editor’s note: Mental Health America (MHA) on Aug. 23 announced the resignation of its president and CEO, Wayne W. Lindstrom, Ph.D., effective Sept. 19. MHA is currently conducting a national search for a replacement.

I find myself frequently framing today’s realities in mental health within the context of Charles Dickens’ first line in A Tale of Two Cities: “It was the best of times, it was the worst of times.” While many of us are familiar with this beginning quote, we are less familiar with the remainder of his opening line, which next goes on to say “it was the age of wisdom, it was the age of foolishness.” Today I am increasingly astonished by evidence of the age of wisdom. We are learning almost daily of new discoveries in neuroscience, genetics and technology that offer us leaps forward in effective prevention, early intervention, treatment and recovery. Simultaneously I find myself stunned at hearing of another impact of sequester cuts on government-funded research that has been propelling these leaps forward.

Dickens goes on to say “it was the epoch of belief, it was the epoch of incredulity.” With the passage of the Mental Health Parity and Addiction Equity Act (MHPAEA) and the requirement under the Affordable Care Act (ACA) that mental health services be fully integrated within the rest of healthcare, I had come to believe that mental health services would no longer be delivered within a separate and inferior care system. But now I find myself incredulous over the almost $5 billion that has been lost to the publicly funded mental health service system over the last five years due to state budget cuts, and over the machinations by elements of the Republican Party to dismantle the very vehicle I had come to believe in, “ObamaCare.”

The validity of Dickens’ commentary applied to our field and in our time does not end there for me. He goes on to further say “it was the season of Light, it was the season of Darkness.” When I look at how far consumer and family empowerment and recovery have come, I am convinced we are all embraced by a “season of Light.” But when I hear voices calling for more involuntary commitment options and for more inpatient psychiatric beds, rather than intensive and comprehensive community-based treatment capacity, I feel a “season of Darkness” is upon us.

As we begin to more fully understand neurophysiological brain development during the first five years of life and we begin to implement evidence-based services and supports that make for resilient children, who can withstand the stressors of life and be launched on a healthy life trajectory, it is indeed “the spring of hope.” But for me, when we fail to treat gun violence as a public health problem and prohibit, by law, the Centers for Disease Control and Prevention (CDC) to even study it, and when we permit our children to be gunned down not only in Newtown, but also on the streets of Chicago, then “the spring” for me, turns to a “winter of despair.”

As in Dickens’ writing, we have “everything before us.” We are becoming a global community that is experiencing rapid technological and social change. I look around and see us beginning to grow our own food again, becoming not only increasingly health- and wellness-conscious, but also mindful and respectful, while holding ourselves, others and the Earth in reverence. With this new consciousness, the elimination of health inequities and discrimination against those with mental health or emotional conditions, and others who are thought to be different, is indeed possible. But rapid change creates anxiety and a sense that events are beyond one’s control. The associated fear-based reactions are an attempt to restore the old order, to return to fundamental beliefs, systems and institutions. We witness this desperation playing itself out even within the halls of the U.S. Congress and around the world. Should fear dominate our choices, then we have “nothing before us.”

We need to stand firm against fear-based reactions but not become fearful and angry reactionaries in response to those who express them. To do so will result in us “going direct the other way” rather than “going direct to Heaven,” as Dickens said as he drew his opening to A Tale of Two Cities to a close. For me, Gandhi ultimately said it best for all of us: “Be the change you want to see in the world.”

Wayne W. Lindstrom, Ph.D., is a 42-year veteran of the behavioral health field. His last position was as president and CEO of Mental Health America.

The National Quality Forum (NQF), a nonprofit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting, and build consensus on national priorities for performance improvement, reported in July preliminary quality measures to the Centers for Medicare & Medicaid Services (CMS) for the CMS-state demonstrations for persons dually eligible for Medicare and Medicaid. Officials and advocates are considering the application of these measures for Medicaid managed long-term services and supports (MLSS) programs.

It is estimated that there are now 10.5 million persons dually eligible for Medicare and Medicaid. Previous data (based on nearly 9 million eligible people) included 5.5 million low-income seniors and 3.4 million people with disabilities under the age of 65. Sixty-six percent of the beneficiaries have three or more chronic conditions, and 86 percent of these persons have incomes below 150 percent of poverty.

The July NQF report to the CMS estimated that 58 percent of dual-eligible beneficiaries have a serious mental illness (SMI) or other type of mental impairment. Within that group, 20 percent have more than one mental illness or impairment. An estimated 20 percent of disabled dual beneficiaries younger than 65 have substance use problems. Nearly 7 percent of dual-eligible beneficiaries between the ages of 18 and 64 have an intellectual and/or developmental disability (ID/DD).

Identification of quality measurement gaps

To be endorsed by the NQF, a measure must be national in scope and have a data steward (to manage, collect and report data). Most existing measures being examined are traditional medical treatment–focused — delivered in medical treatment settings by medical professionals. Some of the measures specifically exclude persons with disabilities, including persons with mental illness. The NQF identifies gaps in quality measures — outcomes we want to measure but currently aren’t systematically capable of, given the steward and related requirements.

In spring 2012, the Consortium for Citizens with Disabilities (CCD) Task Force on Long Term Services and Supports identified six gaps in existing quality standards as they directly relate to persons with disabilities, with a focus on home- and community-based services and settings, to be pursued within the NQF (see MHW, Jan. 28, 2013; Sept. 17, 2012).

In the July 2013 NQF to CMS preliminary findings, seven high-priority measure gaps are identified:

Goal-directed, person-centered care planning and implementation;

Shared decision-making;

Systems to coordinate healthcare with nonmedical community resources and service providers;

The July 2013 NQF preliminary findings to the CMS endorsed 45 measures. Most of these are chronic illness condition–specific and are traditional medical treatment–focused — delivered in medical treatment settings by medical professionals. There are a few exceptions.

The report identifies a “starter set” of 15 measures for “immediate implementation”:

Initiation and engagement of alcohol and other drug dependence treatment;

Free E-Alerts

Subscription Formats

Valerie Canady, managing editor of Mental Health Weekly, knows the mental health field inside and out. She uncovers the essential stories and gets the scoop directly from leaders and advocates in the field.